Memorial Case

Study
Sylvia Chen
Dietetic Intern, Illinois State University
Memorial Hospital
Patient Introduction

• Initials: T.M.
• Admitted 11/03/21

• Age: 67YOM

• Height: 185cm (6’1”)

• Weight: 129.0 kg

• Attending physician: Traves Crabtree MD

• Floor: C6, then transferred to E6 on 11/06

This Photo by Unknown Author is licensed under CC BY-SA

Previous
Medical
History

• PMH
• Distal esophageal
adenocarcinoma, HTN,
DM II, diverticulosis,
anemia, esophagitis,
hemorrhoids,
hypercholesteremia

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Present Admission

• Reason for admission: Distal Esophageal adenocarcinoma

• Procedures: Esophagectomy, Thoracotomy, J tube placement(11/03)

• Imaging

• D Chest Vw (11/3-11/8)
• Line/Tube Placement

• D UGI w Iodinated contrast (11/09)

• Leak

• CT chest, Abd/Pel wo contrast. Wo contrast (11/10)

• Leak
Esophageal
Cancer
• Adenocarcinoma 1
• Most common form of
esophageal cancer
• Tumor in gland cells
• Mucus-secreting
• Lower portion of
esophagus
• Risk Factors
• Male, Age, Caucasian,
Obesity,
Smoking/Alcohol,
Barrett’s esophagus
https://histology.siu.edu/erg/GI060b.htm
Esophageal Cancer

• Symptoms 1
• Early stages asymptomatic

• Dysphagia*

• Unintentional weight loss*

• Odynophagia

• Dyspepsia

• Chest pain

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Esophageal Cancer

• Treatment
• Stage-dependent: Localized, Regional, Distant
2
• Localized (Stage I – Stage IIB)
3
• T1-T3, N0, M0
• Mucosa
• Minimal lymphatic spread

Endoscopic mucosal resection

Esophagectomy 2
Neoadjuvant chemoradiation

https://histology.siu.edu/erg/GI005b.htm
Esophageal Cancer

• Treatment
• Stage-dependent: Localized, Regional, Distant
2
• Regional (Stage IIB – IIIC)
• T1-T4, N1-N3, M0 3
• Mucosa
• Moderate lymphatic spread

Esophagectomy w/ lymphadenectomy
2
Chemotherapy/chemoradiotherapy

https://histology.siu.edu/erg/GI005b.htm
 Esophageal Cancer

• Treatment
• Stage-dependent: Localized, Regional, Distant

2
• Distant (Stage IV)
• T1-4, N0-N3, M1 3
• Metastatic disease

Brachytherapy*
Chemotherapy*
Jejunostomy/gastrostomy*
Esophageal bypass surgery* 2

https://histology.siu.edu/erg/GI005b.htm
*Palliative treatment
Esophageal Cancer

• Surgical Complications 1
• Laryngeal nerve injury, anastomotic leak, chylothorax
2
• Prognosis
• Stage-dependent
• Overall poor
• 5-year survival rates 10-15%
• Up to 75% esophageal adenocarcinomas too advanced for curative therapy
• Stage IV patients – 5% five-year survival rate
Pt Medical Treatment

• Medical and/or surgical measures

• Neoadjuvant chemoradiation (PTA)
• Ivor Lewis Esophagectomy (11/03/21)
• Thoracotomy + Abdominal incision
• Esophagogastric anastomosis
• J Tube Placement (11/03/21)

• General Progress This Photo by Unknown Author is licensed under CC BY

• Overall, good
• Repeat PET scans showed great response to neoadjuvant treatment prior to surgery
• No additional evidence of cancer
Medical Nutrition Therapy

4
• EAL on cancer

• Nutrition status is associated with quality of life in adult oncology patients (Strong Evidence)

• Nutrition status is associated with increased hospital LOS in adult oncology patients (Strong Evidence)

5
• EAL on esophageal cancer

• Can nutrition intervention reduce treatment-related complications for esophageal cancer patients

recovering from chemoradiation therapy? (Weak Evidence)

Research Article - Nutrition in Peri-Operative Esophageal
Cancer Management
• Main takeaways:

• Oral intake contraindicated during first postoperative days (unsupported by solid

evidence)

• 2 RCT studies found early oral feeding is safe and associated with reduced LOS

• Compared with NPO and TF

• Early enteral nutrition is preferred over parenteral nutrition

Research Article - Nutrition in Peri-Operative Esophageal
Cancer Management

Overall
• Research in nutrition assessment and intervention for esophageal cancer pts is scarce

• In general, dietitians and nutrition care team should assess each patient

individually with known nutritional status indicators (intake, body weight, body comp)

and clinical judgement

Medical Nutrition Therapy

• Diet Order: NPO

• Energy Needs: 2565-3135 kcal, based on AdjBW (95kg)

• Percent IBW 154%

• Protein Needs: 110-133 gm (1.2-1.4 gm/kg)

• J-tube (placed 11/03)

• Nutrition hx: Eating well, stable wt PTA

• Labs: Glu high , Ca low

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 Energy Needs: 2565-3135 kcal, based on AdjBW (95kg)
Percent IBW 154%
Protein Needs: 110-133 gm (1.2-1.4 gm/kg)

Medical Nutrition Therapy

• Nutrition Care Plan:

• 11/5: Start Jevity 1.5 via J-tube @ 10mL/hr (12% kcal needs)

• 11/8: Jevity 1.5 @ 20mL (25% kcal needs)

• Advance to goal: 80mL/hr

• 11/10: Running 80mL/hr at visit

• C/O diarrhea

• Decrease to 60mL/hr, adv 5mL q8h (98% kcal needs)

• 11/11: CL diet

• Jevity 1.5 @ 140mL/hr x 12 hrs (Nocturnal feed)

What would I have done differently?

• Decrease rate sooner

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Questions?

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References
1. Elles Steenhagen, Jonna K. van Vulpen, Richard van Hillegersberg, Anne M. May & Peter
D. Siersema (2017) Nutrition in peri-operative esophageal cancer management, Expert
Review of Gastroenterology & Hepatology, 11:7, 663-
672, DOI: 10.1080/17474124.2017.1325320
2. Short, M. W., Burgers, K. G., & Fry, V. T. (2017). Esophageal Cancer. American family
physician, 95(1), 22–28.
3. Berry M. F. (2014). Esophageal cancer: staging system and guidelines for staging and
treatment. Journal of thoracic disease, 6 Suppl 3(Suppl 3), S289–S297.
https://doi.org/10.3978/j.issn.2072-1439.2014.03.11
4. Academy of Nutrition and Dietetics. Evidence Analysis Library. Oncology (ONC)
Systematic Review (2011-2013).
5. Academy of Nutrition and Dietetics. Evidence Analysis Library. Oncology (ONC) by Topic
Systematic Review (2005-2007)/ONC: Nutrition Support and Intake (2006-2007)